Urology

Introduction:

Welcome to the Urology CASES webpage. We hope you will find the links and videos educationally useful and relevant.
The Pie chart shown below represents the breakdown of urology referrals received into CASES until January 2017. Around 12% of the referrals were sent back to practices with advice on management that can be carried out in primary care. A further 3% were sent back to practices asking for more information to be included in the referral letter before sending on to secondary care.

 

Dr Michael Boyle, Dr Magdy Shenoda and Dr Rowan Kenny peer review urology referrals for CASES. They are supported by Mr Derek Rosario, Consultant urological surgeon from Sheffield Teaching Hospitals NHS Foundation trust who provides mentorship advice.

Educational materials and advice

Please contact PCS if you feel you would benefit from receiving CASES information based on individual GP or Practice referrals for reflective learning (please note this can support CPD training and appraisal).  You may wish to use the below template:

Record of learning template

Video:

In the following video, Dr Michael Boyle discusses erectile dysfunction and its management in primary care

During the video above Dr Boyle references a video called ’23 and 1/2 hours’ which is an interesting video explaining the benefits of exercise.  You can watch it below:

 

Useful links:

1. Urological notes from the PLI

2. British association of urological surgeons 

3.  The Urology Department, Cambridge University Hospitals NHS Trust

Urology Top Ten Hints

1. When doing a LUTS referral, please look at the continence pathway. [Hyperlink to latter] Note that many conditions give rise to LUTS other than the prostate and the bladder, and that a bladder diary is very helpful. It encourages the patient to take an interest in their own health and improves diagnosis and treatment decisions. A full LUTS work up prior to referral is very helpful, plus encouraging lifestyle advice may lead to more self-management.
2. Peyronie`s Disease is a distressing condition, often painful initially, settling normally in time. Surgery is often not necessary unless intercourse is problematic.
3. Hydrocele: Based on ultrasound report, only refer if patient has significant symptoms. Aspiration is not recommended any more
4. Prostatitis: check for any sexually transmitted disease in men under age of 40 years of age. For chronic prostatitis: try ciprofloxacin for one moth with NSAID if not contra-indicated, before considering referral
5. Persistent Sterile Pyuria: Always rule out chlamydia in younger patients and swab any vaginal discharge in females. Arrange for ultrasound scan before referral
6. Haematospermia – (see NICE CKS guidelines ) . In younger men this is usually self-limiting but do consider examining and investigating for STIs, UTIs, prostatitis and untreated hypertension. Consider a urology referral only in the following groups:

• Men over 40 with no other cause found
• Any man with findings suggestive of a prostate or testicular/urological malignancy
• Any male who has had 10 or more episodes of haematospermia without any identifiable cause
• Where investigations suggest that cysts or calculi of the prostate or seminal vesicles is the cause
• Where haematospermia continues despite treatment of suspected underlying cause

Remember that if men have had an invasive procedure on the prostate that haematospermia should resolve within 3 to 4 weeks

7. Erectile dysfunction – this can be a CVS red flag. A full CVS work up is warranted. Many of these patients can be managed in Primary Care.

(BASHH guidelines) PDe5 inhibitors are effective in up to 80% of patients with ED but remember:

• Give sufficient tablets for a reasonable trial. If men have not had adequate erections for some time ( which is common at presentation)       then supply enough doses for them to try regularly for up to 4 weeks e.g. sildenafil 50mg 12 tablets ( 3 times a week for 4 weeks)
• If men don’t at first respond to generic sildenafil, consider a trial of tadalafil, vardenafil or avanafil as a second or third agent trial may be effective. Remember though that these drugs are still subject to Schedule II restrictions so may only be available to some patients on a private prescription

8. Suspected renal tract calculi – see SUSS (Sheffield urinary stone service guidelines for management of suspected stones in primary care before referring).
9. Foreskin problems – when considering routine referral for circumcision (any suspected penile mass should be referred by the 2ww pathway) please consider and record in the referral letter the following

• Is the patient suffering any discomfort or adverse symptoms as a result of his tight or non-retractile foreskin?
• Is the patient willing to undergo circumcision

Most common reasons for circumcision are

• phimosis causing difficulty passing urine ( though ballooning alone is not necessarily an indication for circumcision )
• dyspareunia
• recurrent symptomatic skin disorders such as infective balanitis or BXO

10. Urological investigations generally – if you are undertaking investigations for loin pain or indeed any other undiagnosed condition, please see and append any appropriate results before referral as often these may impact on the decision to refer in the first place. Please also remember at CASES we do not have access to ICE for referred patients.

 Meet the review team

 

 

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